Eating Disorders and Alcohol Use Disorders

Alcoholism and eating disorders frequently co-occur and often co-occur in the presence of other psychiatric and personality disorders. Although this co-occurrence suggests the possibility of common or shared factors in the etiology of these two problems, research to date has not established such links. Regardless of the precise meaning of the association, the reality that eating disorders and alcohol use disorders frequently co-occur has important implications for assessment, treatment, and future research.

research centers with specific recruitment requirements, the majority of patients who present for treatment for eatingrelated problems are "partial syndrome" or EDNOS cases. That is, they fail to meet all the diagnostic requirements for one of the "formal" EDs but they have significant symptoms and associated problems. Indeed, researchers have questioned the significance of the failure to meet some of the specific criteria (such as the necessity that amenorrhea be present in female patients for a diagnosis of AN to be made). Investigators have also claimed that some of the diagnostic criteria for the formal EDs are too stringent (Andersen et al. 2001;Striegel-Moore et al. 2000). Many patients experience significant and clinically meaningful problems with eating and body image, but do not always fulfill the exact requirements for the diag noses of AN or BN.
Binge Eating Disorder, included as a provisional category in the DSM-IV, is a specific example of an EDNOS. BED is characterized by recurrent episodes of binge eating (an average of 2 days with binge episodes per week over a 6-month period is required; marked distress exists because of the binge eat ing) without the compensatory weight control methods that are required for the diagnosis of BN (Grilo 1998(Grilo , 2002a. BED, unlike AN and BN, is not uncommon in males or in people of color. It is most frequently seen in adults, and has an estimated prevalence of 3 percent in adults and roughly 8 percent in obese persons . BED is associ ated with increased risk for obesity and thus for the plethora of medical problems associated with obesity (Grilo 1998).

Age Ranges and Gender
Eating disorders most frequently develop during adolescence or early adulthood, but their onset can occur during childhood or much later in adulthood (Grilo 2002a). The peak age range for onset of AN is 14 to 18 years, although some patients develop AN as late as their 40s (Frey 1999). Similarly, the peak age range for BN is adolescence through early adulthood (Lamb 1999). BED most frequently occurs in young to middle adulthood (Grilo 1998). Although developmental challenges and severe dieting generally predate AN and BN, it appears that a significant proportion of people with BED report no dieting prior to the onset of binge eating (Grilo 1998(Grilo , 2002a. Although AN and BN occur mostly in females and BED is more common in females than males, it is important to not overlook these EDs in men (Andersen 1995;Andersen and Holman 1997). Available research sug gests that among ED patients, few gender differences exist in the specific features of the EDs (Barry et al. 2002;Woodside et al. 2001).

Co-Occurrence of Substance Use Disorders and Eating Disorders
Most studies have reported that EDs and SUDs frequently co-occur, with especially high rates observed among patients in treatment (e.g., Beary et al. 1986;Brewerton et al. 1995;Bushnell et al. 1994;Goldbloom et al. 1992;Grilo et al. 1995b;Higuchi et al. 1993;Suzuki et al. 1993;Taylor et al. 1993; see reviews by Grilo et al. 1995a andHolderness et al. 1994 for more complete listings of earlier studies).
Although research has generally reported high rates of co-occurrence between EDs and SUDs, perhaps most strik ing is the marked inconsistency or variability in the reported co-occurrence rates across studies. A previous review (Holderness et al. 1994) noted that estimates of BN in patients with SUDs ranged from 8 percent to 41 percent and estimates for AN ranged from 2 percent to 10 percent. Methodological issues account, in part, for some of the inconsistencies in the reported co-occurrence rates and make interpretation of the literature ambiguous. Variations in recruitment methods (community versus treatment samples, and, if using treatment samples, the type of treatment facility [e.g., general psychiatric, substance or chemical dependency, eating disorder; inpatient versus outpatient]) and assessment and diagnostic methods (survey, self-report, diagnostic interview) account for some of the variability in the literature.
These important methodological limitations notwithstand ing, research does suggest that EDs and SUDs frequently co-occur. Therefore, research seeks to determine the signifi cance of the co-occurrence for informing (a) models of etiol ogy and pathophysiology, and (b) approaches to treatment and clinical management. The remainder of this article will review this research, first examining the prevalence of the co-occurrence of EDs and SUDs in more detail and then exploring whether research supports the possibility of com mon or shared factors in the etiology or maintenance of EDs and SUDs.

Co-Occurrence versus Comorbidity
"Comorbidity" is a widely used term in psychopathology research but one that appears to reflect various meanings or definitions. Kendall and Clarkin (1992), among others (Grilo 2002b), noted numerous possible meanings of comorbidity, including random co-occurrence of disorders that are inde pendent, co-occurrence of different disorders that share a common etiology, or different disorders that have a causal relationship between them. Comorbidity may reflect, in part, artifacts of the diagnostic systems because of criterion overlap (e.g., one criterion for borderline personality disorder is "impul sivity," which can be met in part by binge eating and/or by substance use). As demonstrated initially by Berkson (1946), and more recently by duFort and colleagues (1993), studies of treatment-seeking patients must be interpreted cautiously because of biases (i.e., people seeking treatment may have especially severe problems, people with multiple problems may seek treatment for one or several of the problems) that can make interpretation of comorbidity difficult and may limit generalizability to community samples. Thus, a starting point for possible comorbidity is when rates of co-occurring diagnoses are statistically different from those expected, given the base rates for the individual disorders (Kraemer 1995). Allison (1993) maintained the importance of selecting "rele vant" control or comparison groups to provide a context for interpreting differences in co-occurrence patterns. Appropriate comparisons might include psychiatric patient groups without the eating and/or alcohol use disorders.
Controlled studies (Dansky et al. 2000;Grilo et al. 1995a,b;Wiseman et al. 1999) have suggested that some of the apparent co-occurrence between EDs and SUDs may be related, in part, to other psychiatric comorbidities. Specifically, Dansky and colleagues (2000) reported that the relationship between BN and alcohol use disorders reported by the National Women's Study was likely indirect and groups has revealed that, although EDs the result of associations with other psyand SUDs co-occur, the co-occurrence chiatric disorders, most notably major is either not significantly greater or-if depressive disorder and post-traumatic so-is only marginally greater than the stress disorder. Grilo and colleagues co-occurrence rate in relevant compari-(1995b) compared inpatients who had son groups (i.e., patient groups of com-ED with and without SUD with a parable sev context as opposed to the frequently not ED. In this controlled comparison, used "normal" control group). Grilo personality disorders characterized as and colleagues (1995a, 1995b) found cluster B (i.e., erratic or unstable) were that, although EDs are frequently diag-diagnosed more frequently in the patients nosed among inpatients with SUDs, they are also frequently diagnosed in other psychiatric inpatients. In this con-with co-occurring ED and SUD, whereas cluster C personality disorders (i.e., anxious or fearful) were diagnosed more erity chosen to provide a comparison group who had SUD but trolled study, the frequency of AN and frequently in patients with ED without BN was not greater in patients with co-occurring SUD. This three-group SUDs than without SUDs. Subthreshold manifestations of comparison allowed for a finer distinction regarding potential EDs (i.e., EDNOS; cases where insufficient criteria were comorbidity and raised the possibility of subgroups of patients present to warrant either BN or AN diagnoses) were diag-(e.g., with borderline personality disorder) who might be most nosed significantly more frequently in the patients with likely to have problems with both eating and substance use SUDs than without. Some research has also suggested that disorders. Consistent with this, Bulik and colleagues (1997) patients with nonpurging AN may be less likely than patients found that, although women with alcoholism and BN had with other forms of EDs, including AN purging subtype, to higher rates of a variety of psychiatric problems than women have SUDs. The increased possibility for SUDs to co-occur with BN without histories of alcohol use disorders, multiwith atypical manifestations of EDs, rather than with AN variate analyses revealed that borderline personality disorder and BN, is examined further in the following section.
was the sole distinguishing variable between the two groups. The three studies of comorbidity in BED that used rele-Most recently, Wiseman and colleagues (1999) found that the vant comparison groups found high rates of lifetime alcohol order of onset of the two disorders might be important. Patients use and SUDs but not higher rates than observed in the who developed EDs early and prior to SUDs had greater levcomparison groups (Telch and Stice 1998;Wilfley et al. els of psychiatric and personality disorder psychopathology com-2000; Yanovski et al. 1993). Most recently, von Ranson and pared with patients who developed the ED after the SUD colleagues (2002) reported findings from a large community and with patients who had an ED but no SUD. study of two groups (672 adolescent girls, 718 adult women) These findings suggest that additional psychiatric disorders assessed using diagnostic interviews. The authors reported frequently co-occur with EDs and SUDs, and may play a role that EDs and substance use were positively related, but the in their relationship to each other. In particular, these findings association was not significant. They concluded that there is suggest that patients who suffer from both eating disorders and no strong overarching relationship between these problems.
substance abuse disorders may have deficits in impulse control. These findings suggest caution in interpreting comorbidity Related to this line of investigation, recent years have witnessed between different forms of EDs and SUDs.
increased attention to the potential role of childhood abuse, perhaps mediated by personality disorders, as a common factor Other Comorbid Psychiatric Disorders in patients with both EDs and SUDs. Research, however, has not generally supported specific or strong associations between Although this review focuses primarily on the co-occurrence childhood abuse and specific disorders (Grilo and Masheb of EDs and SUDs, both of these classes of disorders frequently 2001; Smolak and Murnen 2002). Another issue to examine in co-occur with other forms of psychopathology. A large body the relationship between these disorders is the significant fre of research has documented associations between EDs and quency with which ED symptoms occur with SUDs.  Grilo and colleagues (1995a) have reported that EDNOS (but not AN or BN) was significantly more common in peo ple with SUD than without SUD. This suggests that it is important for clinicians to consider and screen for subthresh old levels of EDs in addition to formal ED diagnoses. Moreover, assessment of co-occurring subthreshold eating problems may facilitate earlier intervention to prevent later development of the full-blown disorder. A few studies have examined the specific features of EDs present among patients with SUDs (Sinha et al. 1996;Peveler and Fairburn 1990;Jackson and Grilo in press). Sinha and colleagues (1996) assessed eating behaviors and the attitudi nal features of EDs in a community-based sample of 201 young women (ages 18 to 30) who comprised the following four groups: alcohol dependent, alcohol dependent with anxiety disorders, anxiety disorders only, and neither alcohol nor anxiety disorders. Women with alcohol dependence had significantly higher levels of the behavioral and attitudinal features of eating disorders and were more likely to meet the criteria for BN and EDNOS than women without alcohol dependence. Interestingly, these authors found that alcoholism was more closely related to the attitudinal features, whereas anxiety disorders were more closely associated with the behavioral features of eating disorders.

Eating Disorder Symptoms by Gender and Ethnicity
More recently, Jackson and Grilo (in press) examined the specific features of EDs and tested for gender and ethnic differences in a racially diverse group of outpatients with SUDs. Similar to previous studies with primarily Caucasian samples (Peveler and Fairburn 1990;Sinha et al. 1996), eating-related problems were not uncommon in substance abusers. Roughly 20 percent of men and women reported binge eating, and 12 percent reported some form of inappropriate weight compensatory behaviors. Problematic attitudes about body shape were also common; 28 percent of the Jackson and Grilo (in press) sample reported overvalued ideas regarding shape at levels considered to be clinically significant-as compared with 28 percent in the study of young women reported by Sinha and colleagues (1996) and 26 percent in the study reported by Peveler and Fairburn (1990). Jackson and Grilo (in press) found no significant ethnic differences in obesity, in features of eating disorders, or in levels of body image dissatisfaction. Men and women were similar in terms of overweight and behavioral features, but women had sig nificantly higher levels of attitudinal features of EDs. Thus, contrary to clinical lore, weight-and eating-related problems are not uncommon in males or in minority groups.

Research Investigating Whether Common Factors May Underlie the Co-Occurrence of EDs and SUDs
The studies described above demonstrate that EDs and SUDs often co-occur and that ED symptoms are significantly more common in people with SUDs than without SUDs. Although research is ongoing, reasons for this co-occurrence have not been reported. One potential explanation is that these disor ders are different manifestations of a common underlying factor. Three types of research provide support for this hypothesis: studies of dieting and substance use, studies of brain chemistry, and family and genetic studies.

Studies of Dieting Behavior and Substance Use
Research has documented significant associations between dieting and eating problems and substance use in younger populations. Krahn and colleagues (1992), for example, found that among college women, increasing severity of diet ing and problems associated with EDs were associated with increased rates of alcohol, cigarette, and other drug use. Krahn and colleagues (1996) also found that dieting during preadolescence (among sixth grade students) predicted future alcohol use. Such findings, when considered with studies showing that food deprivation can increase self-administration of alcohol and other drugs in laboratory animals, are consistent with models positing that common mechanisms may play a role in EDs and SUDs (see Krahn 1991). For example, Krahn (1991) suggested that food deprivation might cause alterations in the central nervous system's reward pathways, thus increasing the consumption of reinforcing substances (e.g., alcohol). However, as emphasized above, and by other reviews (Wilson 1993), the fact that these problems are asso ciated does not demonstrate a specific or common cause.

Studies of Brain Chemistry
Animal studies of brain chemistry have provided some support for the view that EDs and alcohol use disorders may have some shared factors. Some research, for example, has suggested that both disorders may be related to atypical endogenous opioid peptide (EOP) activity. EOPs have been found to influence both alcohol and food consumption (see Mercer and Holder 1997) and may play roles in the control of eating behavior (Berridge 1996;Carr 1996;Cooper and Kirkham 1993;Gosnell and Levine 1996) as well as the development of alcoholism (Reid 1985;Reid et al. 1991; see also Froehlich 1995). In addition, brain neurotransmitter systems, includ ing the serotonin, gamma-aminobutyric acid (GABA), and dopamine systems, are the focus of active research across a wide range of psychiatric and behavioral problems, including food and alcohol consumption (see Mercer and Holder 1997). Particularly active attention has been paid to the role of serotonin, which has been implicated in the control of eating, mood, and impulsivity (Brewerton 1995; Kaye et al. 1998). In addition, treatment studies have reported some support for the efficacy of selective serotonin reuptake inhibitors (SSRIs) across different EDs (Fluoxetine Bulimia Nervosa Collaborative Study Group [FBNCSG] 1992; Hudson et al. 1998;Kaye et al. 2001).

Family and Genetic Studies
Early research reported that people with eating disorders are more likely than those without EDs to have family histories of substance use disorders (e.g., Hudson et al. 1983;Jones et al. 1985). However, several recent large, carefully conducted studies have found that EDs (especially BN) and SUDs seg regate independently in families-that is, eating disorders and substance use disorders most likely do not have the same genetic, familial, and environmental risk factors. For example, Kaye and colleagues (1996) reported that alcohol or other drug dependence was increased only in first-degree relatives of women with BN who themselves also had alcohol or other drug dependence. Schuckit and colleagues (1996), in a large study of alcohol-dependent people and their relatives, also reported weak evidence at best for familial transmission between alcohol dependence and BN. Lilenfeld and colleagues (1997) reported that women with co-occurring BN and SUD have higher rates of problems with anxiety, a variety of personality disturbances including antisocial behavior, and high rates of familial SUD, anxiety, impulsivity, and affective instability. These authors hypothesized that a familial vulnerability for impulsivity and affective instability may contribute to the development of SUD in a subgroup of BN patients. Using data from a large epidemiological sample of female twin pairs, Kendler and colleagues (1995) demonstrated that most of the genetic factors associated with vulnerability to alcoholism in women do not alter the risk for development of BN.

Treatment of Co-Occurring Alcoholism and Eating Disorders
Although alcoholism and other SUDs frequently occur with EDs, research has not established common or shared factors in the etiology or maintenance of this co-occurrence. None theless, the frequent co-occurrence of problems with eating and alcohol may signal greater psychiatric disturbances (Grilo et al. 1995b) and greater medical risk (Catterson et al. 1997;Mitchell et al. 1991). These clinical realities represent considerable challenges to practitioners and researchers. The most common questions include how to identify the presence of possible problems, which problem to focus on first, or whether/how to address both concurrently (Daniels et al. 1999;Wilson 1993;Mitchell et al. 1997). These are important questions and there is a pressing need for research on these treatment issues (Grilo et al. 1997). Not only has little research been done on treating these co-occurring con ditions, but many treatment studies with ED patients either exclude patients with substance dependence or enroll few such patients. Although the brief overview that follows will offer implications for clinicians and researchers in both fields, this section gives a more detailed discussion of the ED inter vention literature for professionals in the alcoholism field.

Assessment and Screening for Eating Disorders
Good, comprehensive assessment of patients is necessary for good treatment. Assessment protocols should involve ques tionnaires (i.e., instruments) that are sensitive enough to flag patients with potential problems for further evaluation. Failure to identify all problems may contribute to poor retention and treatment outcomes even for the targeted problem. Screening instruments for alcohol problems are described in detail elsewhere (Bradley et al. 1998). Although standardized interviews are generally thought to hold important advantages for accurate and thorough assessment of EDs (Grilo et al. 2001a), it may not be possible or practical for many types of clinical facili ties to use them because of cost, time, and lack of training.
The authors of this article recommend two self-report instruments for the screening and preliminary assessment of EDs. The first is the Questionnaire on Eating and Weight Patterns-Revised (QEWP-R) ), a wellestablished and easy-to-complete self-report instrument. The QEWP-R, widely used in research programs, screens for the presence of the specific ED categories and provides useful information about the frequency of problem eating and diet ing behaviors. The second instrument is the Eating Disorder Examination-Questionnaire Version (EDEQ) (Fairburn and Beglin 1994), the self-report version of the Eating Disorder Examination interview (Cooper and Fairburn 1987). The EDEQ offers a number of advantages over other self-report measures and provides detailed information about the behavioral and attitudinal features of eating disorders. The EDEQ has received some support for its utility (Grilo et al. 2001a) and has been used with substance abusers (Black and Wilson 1996). The relative merits of different assessment methods are described elsewhere (Grilo et al. 2001a). Briefly, such instruments are generally thought to underestimate the frequency of some of the behavioral features of EDs (e.g., binge eating) and overestimate some of the cognitive or attitudinal symptoms, compared with interviews (Grilo et al. 2001a). These limitations notwithstanding, such screens are useful for efficiently identifying people with possible problems. Of course, in addition, it is important for clinicians and researchers alike to consider comprehensive medical and psychiatric evaluations for these patient groups (see Grilo 1998). In particu lar, patients with these co-occurring problems require careful medical evaluation and followup (Mitchell et al. 1991). In terms of followup, it may be particularly useful for repeated assessments to include the ED screens. Some clinical experi ence suggests the possibility that successful cessation of substance or alcohol use may be followed by the re-emergence of ED symptoms in some patients. Although this hypothesis awaits conclusive research, it highlights the usefulness of repeated assessments.

Pharmacological Treatments
Pharmacological treatments have generally been found to have little effect on AN either as the primary approach or as an augmentation approach (Attia et al. 1998), although the antidepressant fluoxetine was found to decrease frequency of relapse in one study (Kaye et al. 2001). In contrast, pharma cological treatments, particularly antidepressant medications, have generally been found to be superior to placebo for the treatment of BN (e.g., Agras et al. 1992;FBNCSG 1992;Mitchell et al. 1990) and BED (e.g., Hudson et al. 1998;McCann and Agras 1990;McElroy et al. 2000;see Grilo 1998). It is worth stressing that these studies generally find, particularly for fluoxetine, that high doses are required to produce effects (as high as 60 mg per day in the case of flu oxetine) (FBNCSG 1992). Unfortunately, surveys have revealed that most patients with BN treated with pharma cotherapy by community practitioners received inadequate dosing (Crow et al. 1999). Nevertheless, fluoxetine has also been shown to reduce depressive symptoms and alcohol con sumption in depressed alcoholics (Cornelius et al. 1997). Controlled research testing the efficacy of this medication among women with both alcoholism and EDs is needed.
Medications designed to block the action of opioids (i.e., opioid antagonists) have demonstrated efficacy for reducing alcohol use and relapse, and increasing abstinence rates among alcoholic patients (Anton et al. 1999;Heinala et al. 2001;Mason et al. 1999;Monti et al. 2001;O'Malley et al. 1992;Volpicelli et al. 1992Volpicelli et al. , 1997; see also Krystal et al. 2001). The opioid antagonist naltrexone (ReVia™) has also been studied as a treatment for ED. One study that compared naltrexone, imipramine, and placebo among BED patients found that both medications produced reductions in binge eating but neither was superior to placebo (high placebo response occurred in this study) (Alger et al. 1991). One study found that naltrexone reduced the frequency of binge eating in patients with BN during the first few weeks of treatment but that the effects did not last (Jonas and Gold 1987). A rigorous controlled study is currently under way at Yale University to evaluate the efficacy of naltrexone among alcoholic women and women with both alcoholism and EDs.

Psychological Treatments of Eating Disorders
Cognitive behavioral therapy (CBT) has received the most consistent support of any psychological or pharmacologic treatment for EDs. Briefly, CBT is a focal and structured treatment that involves a collaborative effort between patients and clinicians (Fairburn et al. 1993a). CBT for eating disor ders can be delivered via individual or group approaches and generally follows three phases. The first phase involves edu cation and presentation of the treatment model, including expectations for treatment and homework, teaching behav ioral strategies such as self-monitoring to identify problems, and a graded approach to normalization of eating. The sec ond phase involves the use of cognitive restructuring meth ods to identify, challenge, and modify maladaptive thinking.
The final stage involves relapse prevention techniques and problem solving to generalize the skills to other areas and to consolidate improvements. CBT has been found to be supe rior to control conditions, to most other forms of psycholog ical therapies, to behavioral therapies without the cognitive components, and to the pharmacological treatments (e.g., Agras et al. 1992Agras et al. , 2000Fairburn et al. 1993a; see reviews: Wilson and Fairburn 1998;Grilo 1998Grilo , 2000. Moreover, self-help versions (e.g., Fairburn 1995) of standard CBT therapist manuals (Fairburn et al. 1993b) have demonstrated efficacy (Carter and Fairburn 1998;Peterson et al. 1998;Treasure et al. 1996). This approach may provide general practitioners with expertise in CBT with the technology to help certain ED patients.
Although CBT is generally regarded as the first-line treatment of choice for ED (Agras et al. 2000;Wilson and Fairburn 1998), research is needed to determine its usefulness for patients with co-occurring alcoholism and eating disorders, and to develop integrated psychological treatment approaches for patients with alcoholism and eating disorders (Mitchell et al. 1997). Although the data are sparse, the treatment literature has not suggested that alcoholism or a history of alcoholism diminishes CBT treatment effectiveness for BN or BED (Goldbloom 1993;Mitchell et al. 1990;Wilfley et al. 2000). No available studies have examined whether eating distur bances influence the outcome of alcoholism treatment. Although clinical lore suggests that personality disorders-if present--are associated with negative treatment outcomes, this has not received empirical support in treatment studies of patients with EDs (Grilo 2002b), and findings from treat ment studies of patients with SUD are mixed (Grilo and McGlashan 1999).
Based on clinical experience with both patient groups, the authors suggest that certain CBT-based treatments represent a good starting point for treating co-occurring alcohol use and eating disorders. Basic aspects of the cognitive behavioral approach (e.g., coping skills therapy) have been found effec tive for treating alcohol dependence (Kadden et al. 1992;Monti et al. 1989Monti et al. , 2001 and are useful for ED patients. However, as previously noted, behavioral therapies without the specific cognitive components of CBT have inferior long-term outcomes compared with CBT (Fairburn et al. 1993a). Nevertheless, specific forms of behavioral and coping skills treatments (without the specific cognitive components of the CBT approaches for EDs) have been used successfully with substance abusers and seem to be readily integrated with pharmacological approaches (Monti et al. 2001;O'Malley et al. 1992;Sinha 2000).
Thus, an approach that targets alcohol use and pathologic eating behaviors may be especially appropriate for treating patients with both disorders. Treatment designed to teach new coping skills to patients with alcoholism could also have a beneficial effect on eating disorders even if the ED is not specifically targeted. Given the well-known ambivalence that characterizes many of these patients (e.g., Vitousek et al. 1998), another potentially relevant approach involves motiva tional enhancement interviewing (Rollnick and Miller 1995), which has received some support for SUDs (Project MATCH Research Group 1997) and EDs (Treasure et al. 1999).
Another promising approach is dialectical behavior ther apy (DBT), which initial research supports for both BN (Safer et al. 2001) and BED . DBT, which focuses on awareness of problems and choices, mood regula tion techniques, and coping skills, directly addresses many of the needs of both ED and alcohol use disorder patients, including the frequently co-occurring borderline personality disorder. Indeed, the initial treatment outcome findings for DBT for both BN (Safer et al. 2001) and BED  suggest that addressing a potential vulnerability (e.g., problems with mood regulation and coping) can lead to improvements in ED even without a direct focus on the eat ing behaviors, a finding that parallels that reported for interpersonal psychotherapy (Agras et al. 2000;Fairburn et al. 1993a;Wilfley et al. 1993). Telch and colleagues (2001) speculated that DBT may be particularly helpful for ED patients characterized by high levels of negative affect. Recent studies with BN (Grilo et al. 2001b;Stice and Agras 1999) and BED (Grilo et al. 2001c) revealed two subtypes of these EDs: dietary and a mixed dietary-negative affect. The dietary subgroup was characterized primarily by eating-specific psy chopathology without associated problems with self-esteem and depression (negative affect). Patients with the mixed dietary-negative affect subtype also had high rates of alcohol and other drug problems. It is possible that such patients, particularly if they have problems with impulsivity or have co-occurring borderline personality disorder, might benefit from affect regulation and coping skills approaches such as DBT.

Conclusion
Alcoholism and EDs frequently co-occur and often co-occur in the presence of other psychiatric and personality disorders. Although such diagnostic co-occurrence suggests the possi bility of shared factors in the etiology or maintenance of these problems, research has not established such links. The clinical reality that eating and alcohol use disorders frequently co-occur has important implications for assessment, treat ment, and research. Comprehensive assessment is necessary for good treatment. Research on methods of treating people with co-occurring alcohol and eating problems represents a major need. Until further guidance is provided, the authors recommend concurrently addressing both disorders. CBT, coping skills, or DBT approaches seem to be reasonable starting points. s What is the Link Between Alcohol Use and HIV/AIDS? N ew findings relevant to this and other questions can be found in Alcohol Alert, the quarterly bulletin published by the National Institute on Alcohol Abuse and Alcoholism. Alcohol Alert provides timely information on alcohol research and treatment. Each issue addresses a specific topic in alcohol research and summarizes critical findings in a brief, four-page, easy-to-read format.
Alcohol and HIV/AIDS (No. 57)-examines the role of alcohol in the transmission of HIV within, and potentially beyond, high-risk populations; the potential influence of alcohol abuse on the progression and treatment of HIV-related illness; and the benefits of making alcoholism treatment an integral part of HIV prevention programs.